By: Carlos Arce
For chiropractors and practice owners, receiving a visit or letter from your Personal Injury Protection (PIP) carrier can be unsettling. Whether it’s through a formal notification requesting an interview or an unannounced office visit, such instances demand careful navigation. It’s important to understand the situation, your rights, and the best steps to take to protect your practice.
Even if you have done nothing wrong and your billing is in perfect compliance, this is a matter you need to approach with seriousness and caution. Special Investigative Units (SIUs) or lawyers working on behalf of the insurance carrier do not make these visits lightly, and their primary goal is to uncover fraudulent activity or irregularities. Here’s exactly what to do when they come knocking.
1. Don’t Panic, But Don’t Assume it’s Routine
First, take a deep breath and remain calm. Receiving a visit or correspondence from an SIU agent or attorney doesn’t automatically mean that you’re being accused of fraud. However, it is crucial to treat the situation as seriously as though your compliance and practices were being questioned.
SIU agents are highly trained professionals tasked with protecting insurance carriers from exaggerated claims, overbilling, or fraudulent activity. Sometimes, their visit might only be a “fact-finding mission” to better understand your records and practices. Other times, they may have concerns indicating suspected fraud. The key is to proceed thoughtfully and professionally.
2. Request to Reschedule the Meeting
If an agent or attorney arrives at your practice without prior notice, politely request that they come back and schedule an appointment. While it may feel natural to accommodate them on the spot, this is not advisable, even for a “friendly” interview. By requesting to reschedule, you’ll ensure that the meeting takes place under the proper conditions—with preparation and the presence of your legal representation.
For instance, you can say, “I’d be happy to assist; however, I respectfully request that we schedule an appointment at a later time.”
Remember, the goal is not to be uncooperative but rather to ensure all discussions take place under legally appropriate conditions.
3. Contact Your Attorney Immediately
One of the most crucial steps in your response is to reach out to your attorney as soon as possible. Your attorney will help you understand what is being requested, whether it’s an interview, access to records, or broader compliance concerns. They will also represent you at any future meetings, ensuring your rights and legal interests are protected.
Even if you feel you have “nothing to hide,” the presence of a legal expert ensures that all communication remains clear and professional. Often, agents conducting these inquiries are knowledgeable about insurance law and compliance, which makes having an equally informed representative on your side essential.
4. Understand Their Tools of Investigation
If you decline a “friendly” interview outright without consideration, insurance carriers can escalate their inquiry through more formal measures, such as an Examination Under Oath (EUO) or a 6(b) request. Here’s what those terms mean:
- Examination Under Oath (EUO): This is a formal proceeding where you are questioned by the carrier’s attorney under oath. It is similar to a deposition and may include questions about your billing practices, patient records, or treatment justifications.
- Section 6(b) Request: This refers to a section under the Model Insurance Fraud Act (MIFA) that allows the carrier to request specific information or documents to determine if fraudulent billing practices or patterns exist.
Both of these tools are methods used to uncover insurance fraud. Refusing an initial interview without proper consideration or preparation might inadvertently escalate the investigation to these more formal legal measures.
5. Be Transparent—but Cautious
It’s important to provide requested records and comply with legal expectations, but ensure you’re doing so correctly. SIU agents may ask to review billing records, examine patient treatment plans, or ask specific questions about your practice. These are fact-finding missions designed to assess whether fraudulent billing or overutilization of services has occurred.
While you should remain cooperative, avoid providing off-the-cuff explanations or detailed justifications before consulting with your attorney. Misstatements, even unintentional ones, could complicate the investigation.
6. Understand the Carrier’s Perspective
SIU investigations are often driven by the insurance carrier’s internal processes, not necessarily by a specific intent to target you. The reports and recommendations provided by the agent or attorney will ultimately inform the carrier’s decision on whether insurance fraud is suspected.
For example, if irregularities in billing patterns or treatment frequencies are noted, the carrier might proceed with further actions. By working closely with your attorney to present accurate and complete information, you can reduce the likelihood of such conclusions.
Key Takeaways for Chiropractic Practice Owners
These situations underscore the importance of maintaining strong compliance practices in your day-to-day operations. Here are a few proactive measures that can help:
- Regularly Audit Your Billing Practices: Ensure that your codes, claims, and documentation are accurate, transparent, and defensible.
- Stay Educated: Keep yourself and your team updated on PIP regulations, anti-fraud measures, and insurance compliance best practices.
- Establish a Crisis Plan: Have a protocol in place for responding to SIU visits or inquiries, including knowing whom to contact and the steps to take.
When regulators or insurance representatives seek information from your practice, it’s a serious matter that requires a professional and calculated response. While these inquiries may seem routine or “friendly,” always treat them with the gravity they deserve. By requesting to schedule a formal appointment, involving your attorney, and consciously complying with legal protocols, you can protect your practice and its reputation effectively.
Preparation and proper representation are your greatest tools in these situations.
If you’re unsure how to respond or prepare for regulatory inquiries, consult with a qualified legal professional who specializes in healthcare compliance. Being proactive today can save your practice from considerable stress—and risk—later.
